Medical Website Essentials is Volume 1 of the Ebook Series "Getting Your Practice Ahead" by Technical Dr Inc. to help Physicians and Practice
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The literature on implementing Electronic Health Records (EHR) in hospitals is very diverse. The objective of this study is to create an overview of the existing literature on EHR implementation in hospitals and to identify generally applicable findings and lessons for implementer.
A systematic literature review of empirical research on EHR implementation was conducted. Databases used included Web of Knowledge, EBSCO, and Cochrane Library. Relevant references in the selected articles were also analysed. Search terms included Electronic Health Record (and synonyms), implementation, and hospital (and synonyms). Articles had to meet the following requirements: written in English, full text available online, based on primary empirical data, focused on hospital-wide EHR implementation, and satisfying established quality criteria.
Of the 364 initially identified articles, this study analyses the 21 articles that met the requirements. From these articles, 19 interventions were identified that are generally applicable and these were placed in a framework consisting of the following three interacting dimensions: EHR context, EHR content, and EHR implementation process.
Although EHR systems are anticipated as having positive effects on the performance of hospitals, their implementation is a complex undertaking. This systematic review reveals reasons for this complexity and presents a framework of 19 interventions that can help overcome typical problems in EHR implementation. This framework can function as a reference for implementer in developing effective EHR implementation strategies for hospitals.
Transitioning to a new EMR system is more than simply swapping hardware or adding computers to exam rooms; it changes the way you do healthcare. But despite the well-known importance of a thoughtfully designed implementation process, end-user training is often under-emphasised. From small, single-provider practices to large organisations; end-user training for EMR systems is essential to support efficiency, best practices, and even patient safety.
EHR Training Starts with Dedication
There are countless ways an EHR training program affects overall implementation. But one key advantage of carefully planned training is the opportunity to foster buy-in and commitment from administrators, providers, and staff. Providing examples and evidence of similar practice’s success stories, or improved patient outcomes following computerised provider order entry (CPOE) implementations, can be great ways to encourage dedication to the implementation of a new electronic health records system. Using training as an opportunity to revisit “big picture” goals throughout the process can help maintain enthusiasm and minimise frustration as individuals are charged with learning a great deal of information in what can sometimes feel like a very short period of time.
EHR Training Will Help You be Successful
Insufficient end-user training, along with poorly focused and ineffective EMR implementation, can (and does) lead to adverse consequences in medical practices. These consequences can range from loss of efficiency to medical errors, affecting both a practice itself and its patients. Loss of productivity and job satisfaction can result from inadequate training, but it can also affect a practice’s bottom line as well. Following the purchase of an EHR system, providers rightfully expect a significant ROI through benefits such as fewer billing and coding errors, more efficiency, and more productivity. These benefits are at risk in the event of ineffective training, serving as the culprit for the grievance that an EHR system is somehow not working the way it should.
The Benefits of Quality Training
Even the best EMR system in the world won’t function properly in the absence of well-trained users. As electronic medical records systems proliferate in the healthcare industry, the benefits of developing confident providers through an effective training period are becoming more and more evident. In fact, the importance of end-user training for EHRs has led to the rise of increased related coursework in medical schools and other healthcare provider training programs. Benefits of effective EHR training programs include increased charting and coding accuracy, along with improved productivity and efficiency that benefits both providers and their patients. The practice also benefits from a solid return on its initial investment for years to come.
With all of the organisational change that occurs during an implementation, it’s easy to unintentionally overlook some key aspects of setting up an EHR Training Program. Classroom training and back filling will lead to added, and sometimes unexpected, costs. Additionally, remember that your staff must be trained before they can sign on to the new system. Among other things, failure to keep these factors in mind can result in lost time and may affect your budget. In this post, The HCI Group’s EVP Bob Steele offers three key points to remember during the on-going process of an EHR Training Project.
1) Acknowledge that EHR Training is Amongst the Highest Cost Phases of Your Project
First and foremost, you must accept that training will be one of the highest cost phases of the implementation. The pre go-live training phase will be your end users’ first impression of the system and must introduce a high volume of information in a short period of time. It will affect all aspects of their daily work lives and responsibilities; it can be quite a stressful change if training is not managed well.
You will have costs associated with the appointment of SME’s, analysts, and staff experts for the development and scheduling of the training curriculum and processes. You will incur costs for training the trainers (staff), as well as back filling for their regular duties while they perform training duties. This can become quite expensive as you begin to consider the number of back filled staff required. The final consideration is the costs associated with the actual training of facility staff, sometimes requiring education of over one thousand staff members and providers.
EHR training may include pre-classroom self-studies, classroom training, and, in some cases, simulation labs – all of which can take anywhere from 4-6 hours to 2-3 days, depending on position and job responsibilities. Again – depending on Service Line Area – these positions may need to be back filled, which will add cost.
One way to avoid the cost of back filling is by utilising third-party vendors. While third-party vendors may seem to be the more expensive option, the cost of training and relieving facility trainers, as well as having to back fill to cover their regular duties, may turn out to be more costly.
2) Scheduling and Flexibility Within Your EHR Training
Day-to-day Patient Care (Safe Patient Care) and business operations must go on. Match the total number of end users to be trained with your available classrooms and computers to determine the number and amount of classes to be offered. Hands-on computer classroom training is imperative. Remember, back-fill or relief from regular responsibilities is not an option for some (especially the provider group). Consider weekend, evening, and even night shift classroom training to accommodate end user needs.
A good practice is to incorporate a variety of learning methods and methodologies to address all types of learners. This includes self-studies, web-based training, simulation labs, mock go-lives, and of course, traditional classroom and hands-on training. Try to avoid disruption of daily responsibilities as much as possible and increase overall compliance numbers of those who are successfully trained by go-live. One of the best ways to ensure your staff is adequately trained is to enforce “no training, no sign-on.” Before users can access the new system, they absolutely must have completed their training program.
3) EHR Training is a Never Ending Process
Understand that training is a never-ending process. After go-live, training and training costs will transition from a project cost to an ongoing operational cost. There will be continuous training of new staff hires and providers, as well as frequent system and application upgrades. Medicine and Industry standards and changes in areas such as clinical best practices, quality measures, and meaningful use will also be prevalent. Training is an ongoing journey, so it is important to have a well-oiled and independent facility team to carry on the process.
Training is a pivotal part of any new EHR implementation. Keeping these three key aspects in mind will help your organisation prepare for this important phase and the challenges it can bring. These principles make up a small piece of the EHR training process.
About $19.2 billion of the $787 billion American Recovery and Reinvestment Act (ARRA) that President Obama signed in 2009 is directed as an electronic medical records stimulus. The administration is working to complete the movement to EMR integration because it believes there are many benefits of electronic medical records use, including streamlining patient care and providing long-term savings in the health field. The electronic medical records stimulus also provides financial incentives to help physicians convert to the paperless electronic medical record systems, but reports have found that even without the incentives, there are real benefits of electronic medical records and electronic health records integration.
Benefits of Electronic Medical Records to Medical Practice Operations
Proponents of EMR/EHRs also argue that digital medical record storage helps prevent filing errors. Most paper patient records are not backed up in a secondary location. Medical records storage through digital means eliminates any threats of losing the patient health information in an emergency. Many electronic medical record systems are backed up every day automatically and are accessible almost anywhere in the world.
Cost Benefits of EMR / EHR
A 2003 study by the University of California that focused on solo and small group physicians found that though results greatly varied, some physicians saved up to $20,000 per year through electronic medical record systems adoption.
“More successful users decreased transcriptionist, medical records, data entry, billing, and receptionist costs,” states the report.
About 42 percent of active family doctors have already installed at least preliminary electronic medical record systems, according to surveys and estimates by the American Academy of Family Physicians, a professional and advocacy group. Though not all physicians have seen the benefits of electronic medical records implementation promoted by the government, many firms have begun to leverage the advantages of EMR, bringing their patients higher quality care for less cost.
“I’ll never go back to the old system,” Dr. Jennifer Brull, a family doctor in rural Kansas, told the New York Times. “I can always look at the records by Internet, whether I am seeing patients at the nursing home or a clinic or the hospital, or even when I’m as far away as Florida. The change has been tremendously beneficial for my productivity.”
According to a 2014 report, only 50.7% of providers are using a fully-functional EHR — and more than 40% of providers using an EHR are thinking about switching their system. Selecting the right EHR system can improve patient outcomes and save time and money for your practice, but how do you choose the right one?
Start by finding out what existing users think of their EHR in the 2014 Black Book rankings. Brown-Wilson asks physicians every year to rate the top EHRs on the market for its annual survey. In 2014, over 22,000 physicians participated in the survey, ranking EHRs on criteria such as Support and Customer Care, Reliability, Implementation, and Training.
After you’ve created a list of potential EHRs, contact the vendors to schedule a demo and ask them the questions below:
1. Does this EHR meet my current and future needs?
Establish the requirements (and nice-to-haves) of your new EHR, and see if the vendor’s EHR addresses them.
Questions to ask the vendor:
2. Is it affordable?
Some EHRs have a high initial sticker price. Others may cost less, but require a hefty fee to maintain or upgrade certain features, such as e-prescribing. Others are free, but don’t have all the features or support you need. Spending on EHRs is projected to jump this year, so make sure you know all the current and projected costs of your EHR down the road.
Questions to ask the vendor:
3. Will the transition be easy?
The ability to implement quickly and get your staff up to speed is vital to ensuring a smooth transition for your practice. Cloud-based EHRs can prevent the headache of buying new hardware and installing a system, but any EHR you choose has to be easy to use to make training your staff quick and efficient. Get a clear understanding from the vendor on the implementation process and timeline.
Questions to ask the vendor:
4. What kind of support will I receive?
Even with a system that’s easy to use, helpful and available customer service is key to help you get the most out of your EHR. Some of your staff may require a little extra help to get started, learn a new feature, or understand something like Meaningful Use.
Questions to ask the vendor:
5. Is this EHR certified?
To capture and share patient data efficiently, practices need an EHR that stores information in a structured format. CMS and the Office of the National Coordinator for Health Information Technology (ONC) have established criteria and standards for structured data that EHRs must use in order to qualify for government-sponsored incentive programs.
To get an incentive payment, you must use an EHR that is certified specifically for the EHR Incentive Programs.
Questions to ask the vendor:
To find out what existing users think of their EHR, check out the Black Book rankings. Brown-Wilson asks physicians every year to rate the top EHRs on the market for its annual survey. This year, over 22,000 physicians participated in the survey, ranking EHRs are criteria such as Support and Customer Care, Reliability, Implementation, and Training.
Evaluating your current EHR
Already have an EHR? With spending on EHRs expected to jump as high as 80% by 2015, it’s critical that your practice’s time and money are being spent on the best possible system for your practice.
Evaluate your current EHR by asking the questions below.
1. Is your EHR improving your practice’s efficiency?
If you’ve fully implemented an EHR and you don’t feel your practice is seeing increased efficiency in your day-to-day workflows, then it’s probably time to start evaluating other systems that may work better for you.
2. Does your practice have the support and resources you need?
Regular and ongoing support issues with your EHR are probably a good indicator that there are better solutions to meet your practice’s needs. If technical issues are interfering with your workflow, requiring staff time to resolve, or raising the cost of your EHR budget, it’s probably time to move on from your current vendor. Evaluate if you have all the support and resources you need with the following questions:
3. Is your EHR affordable?
The average physician’s office spends $44,000 over five years implementing an EHR, and only 27% of physician practices report a net positive gain on their investment in an EHR. If your EHR costs are constantly rising, and the incremental costs of operating your system aren’t what the vendor told you they would be, you can find a better solution that meets your needs while still being affordable
Even though only 26% of physicians access their EHR from a tablet or mobile device, those users are more satisfied with their EHR system, according to the new EHR. User View Survey from Software Advice. The survey polled nearly 600 physician users about their current EHR systems’ key benefits and challenges and their future healthcare IT investment plans.
Fifty-eight percent of users who accessed their EHR from a mobile device were “very satisfied” with their EHR, compared to 28% of non-mobile users.
Mobile users may be more satisfied with their systems because they were less affected by common EHR challenges in learning to use the system. Thirty-nine percent of mobile users expressed that learning how to use their EHR system was challenging, compared to 58% of non-mobile users. The report said that this discrepancy may be because mobile users take their mobile devices home and learn to use the EHR system outside of normal working hours.
Plus, physicians embrace using smartphones, as 47% of physicians already use mobile devices for clinical purposes, and most physicians (89%) use smartphones to communicate with hospital staff. A 2013 Black Book Rankings survey found that 83% of doctors would use mobile EHR apps to update charts, check labs and order medications if their current EHR vendor made those features available for mobile.
When asked what EHR modules and applications physicians planned to invest in more heavily in the future, EHR User View Survey respondents said they were most interested in increasing their investment in patient portals (36%), followed by e-prescribing, health information exchange and lab integration.
The use of electronic health records that can securely transmit patient data among physicians will help coordinate the care of 60 million Americans with multiple chronic conditions. This article summarises the different organisations in the United States that are developing this technology. It discusses some of the problems encountered and the current initiatives to resolve them. The article concludes with three recommendations for enhancing care coordination: (1) a common health record, such as the Continuity of Care Record, to facilitate the exchange of clinical information among health providers; (2) regional governance structures to encourage the exchange of clinical data; and (3) payment by purchasers of care, both public and private, to physicians for using electronic health records.
Appropriate medical care for people with multiple chronic conditions requires that clinicians be able to communicate with one another about their patients. Unfortunately, in today's medical care system, many clinicians are unable to communicate easily and efficiently with their colleagues. In a series of reports, the Institute of Medicine (IOM) named ineffective care coordination as a cause of poor care and initiated a series of reports recommending electronic health records as one way of improving its quality (Institute of Medicine 2003b; Institute of Medicine, Board on Science Technology 2001). The greatest burden stemming from this lack of easy and effective care coordination is for the 60 million Americans with multiple chronic conditions (Anderson and Knickman 2002).
Problems with the Current Paper-Based System
Participants at a joint IOM–Kaiser Permanente Institute for Health Policy conference in 1992 agreed that the paper-based information systems still used by most clinicians are not well suited to good-quality care, especially for persons with multiple chronic conditions (Raymond and Dold 2002). The conference concluded that paper-based systems supporting clinical care are limited as information storage and retrieval systems and have high rates of failure in retrieval and illegibility; that human memory–based medicine is increasingly unreliable; that the capture of clinical data has become necessary for billing, appointment scheduling, prescription refills, and results reporting; and that consumers’ expectations for improved care and service are rising. Their proposed solution was the creation of electronic clinical information systems.
Increasingly, the medical care field is recognizing that it is far behind most other industries in using electronic data (Shortell et al. 1996). At one end of the continuum is the highly visible and advanced use of technology such as the remote sensing of bodily functions and the revolution in radiology and surgery based on the ability to digitize and communicate information (McDonald et al. 1999). At the other end of the continuum are the communication methods used by the majority of U.S. clinicians, who rely on paper medical records and coordinate care by “playing phone tag” with other clinicians and social service providers caring for the patient.
Some provider groups recognised the benefits of better communication years ago and developed a prototype EHR. The Computer-Stored Ambulatory Record (COSTAR), one of the first EHRs, was created in the early 1970s at Massachusetts General Hospital (Smithline and Christenson 2002). Some settings, primarily highly integrated networks, have realised the benefits of EHRs. Unfortunately, the level of EHR use among ambulatory care physicians still is low, with estimates in 2002 ranging from 10 to 14 percent of family physicians and 22 percent of all physicians operating as solo practitioners or in small groups (Loomis et al. 2002).
Barriers to the Widespread Adoption of Electronic Health Records
Five of the most important barriers to the widespread adoption of EHRs that would allow clinicians to share information about patients easily and effectively are (1) no common format or standard for recording clinical information, (2) the high costs of implementation and maintenance, (3) no demonstrated clinical and/or financial benefits for ambulatory care physicians participating in shared information systems, (4) patients’ concerns about information sharing and possible loss of privacy, and (5) physicians’ concerns about legal liability.
Standardisation of Clinical Information
The need for a common standard to record and transmit clinical information is widely recognised, with solutions currently being developed by both public and private entities. The Institute of Medicine has addressed the importance of standardisation in several reports and cited the standardisation and use of EHRs as a priority (Institute of Medicine, Board on Science Technology 2001; Institute of Medicine 2003b). The National Health Information Infrastructure, a federal office within the U.S. Department of Health and Human Services, has been established to provide advice and assistance to the department and serves as a forum for interacting with the private sector. Federal health information interoperability standards have been proposed by the federal government's Consolidated Health Informatics Initiative and the National Committee on Vital and Health Statistics and were adopted by the secretary of Health and Human Services for messaging, electronic exchange of clinical laboratory results, standards for retail pharmacy transactions, standards allowing health care providers to plug medical devices into information and computer systems, and standards enabling the retrieval and transfer of images and associate diagnostic information (National Committee on Vital and Health Statistics 2003). The secretary announced the use of these common standards by the Centers for Medicare & Medicaid Services (CMS), the Veterans Administration, and the U.S. Department of Defense as well as an agreement to make Systematized Nomenclature of Medicine–Clinical Terms (SNOMED) a universal health care terminology, available to U.S. users at no cost through the National Library of Medicine (U.S. Secretary of Health and Human Services 2003). Private foundations have helped develop these standards by involving vendors and leaders in the academic fields of clinical data sharing (ehealth Initiative 2002). While these steps are significant, the widespread adoption of these standards will require the willingness of the current owners of EHR systems to find the money to make conversions where necessary and to design EHRs that will attract buyers.
Cost of Implementation and Maintenance
Transferring to an electronic data system where none exists is a major undertaking, requiring a change in work flow, finding a reliable EHR vendor, investing capital in hardware and software, converting records, and training staff. The financial and time costs vary, depending on the extent of the clinical and administrative functions to be managed by the system. Costs also are based on whether the system is purchased outright, leased, or rented. The time that the physician spends entering data at each patient encounter also must be considered. This may be only two or three minutes per patient but may be a major obstacle to the widespread implementation of the system, given most clinicians’ tight time schedules.
Physicians’ Readiness to Adopt the EHR
Physicians need to be convinced that the EHR will enable them to provide better medical care to their patients. Studies of various aspects of electronic clinical data systems have shown that the adoption of an EHR is associated with better health outcomes or processes leading to better outcomes in controlling infection (Fitzmaurice, Adams, and Eisenberg 2002), improving physicians’ prescribing practices (Teich et al. 2000), reducing prescription errors through direct physician order entry and decision support (Kaushal, Shojania, and Bates 2003), preventing serious medication errors in hospitals (Bates et al. 1998; Gandhi et al. 2003), and detecting adverse events in hospital and ambulatory settings after they occur (Bates et al. 2003). Bates and Gawande (2003) have described how information technology leads to many of these safety improvements, such as providing access to information, requiring information and assistance with calculations for dosage of medicines, monitoring, offering decision support, and rapidly responding to and tracking adverse events.
Privacy Issues and Patients’ Concerns with Information Sharing
The 1996 Health Insurance Portability and Accountability Act (HIPAA) affects many aspects of health care information technology and data sharing. The dual intent of HIPAA is to improve administrative efficiency in the health care sector as well as to increase patient privacy protections. The common impression is that HIPAA discourages the sharing of clinical information. However, the administrative simplification rules required by HIPAA may encourage the creation of information systems that can communicate with other systems.
A greater barrier may be the patients’ unwillingness for their clinical data to be shared. One perspective is reflected by the growing numbers of persons with chronic conditions who are being educated to manage by themselves their daily medications or treatment regimens. For such patients, full electronic access to all their medical records offers an opportunity to join their physicians in managing their disease. Several health systems, including the Veterans Administration, are promoting patients’ access to electronic records (Geisinger Health System 2004; Kilbridge 2002). In contrast, Fowles and colleagues (2004) found that only a third of patients were very interested in reading their medical records. Little is known about patients’ attitudes toward sharing their clinical data with different providers. Some patients may want to withhold certain information from doctors, such as a history of mental illness or sexually transmitted diseases.
Over time, patients may come to believe that poorly coordinated care is a significant detriment to a good quality of care and can be rectified in part by better communication among physicians. If this happens, it would motivate health plans and physicians to adopt an EHR. The Foundation for Accountability, a nonprofit national organisation, is actively advocating accountable and accessible health systems “where consumers are partners in their care and help shape the delivery of care” (FACCT 2004).
The legal liability of physicians relying on data from other providers has not been established. For example, case law offers little guidance on the liability of a physician for acting on clinical information made available but not requested. Similarly, there is uncertainty about whether an e-mail message from a patient constitutes part of a medical record for which the physician may be liable (Blumenthal 2002). To assuage these concerns, physicians may need to be educated by legal experts about medical risk management (Grams and Moyer 1997) or actual legal protection. Guidelines and the active involvement of the medical liability industry in designing electronic data systems may be necessary as well.
Current Clinical Data-Sharing Activities
Despite these obstacles, both the public and private sectors are moving forward in adopting systems that share information among multiple clinicians. Next we describe these electronic data exchange activities in seven sectors: patients; ambulatory care physicians; institutional providers; payers, including managed care and commercial insurers; disease management companies; the federal government; and regional initiatives.
Purchasers, providers of care, and government regulatory agencies are increasingly acknowledging the concerns of people with chronic conditions. The Institute of Medicine, bringing together health care professionals and policymakers to improve the quality of care for persons with chronic conditions, has repeatedly advocated computer-based personal health records. The Foundation for Accountability recommends electronic data sharing that allows the consumer full control over and access to his or her health information. The Patient Safety Institute, a national nonprofit organisation, is promoting a common record controlled by both the patient and the health provider (Patient Safety Institute 2001).
Ambulatory Clinical Physicians
There is little empirical evidence of the extent of the adoption of EHRs or the direct value to physicians of shared patient clinical data. One study surveyed medical groups and independent practice associations with 20 or more physicians to determine the extent to which groups use organised processes to improve the quality of care and whether external incentives and clinical data systems were associated with the use of a larger number of care management processes (Casalino et al. 2003). The survey results showed that the percentage of physician groups’ use of clinical systems varied by the functionality: standardised problem lists (18%), progress notes (9%), medications prescribed (24%), medication-ordering reminders and/or drug interaction information (15%), laboratory results (40%), and radiology results (30%). Fifty percent of groups reported no clinical information technology capability. The authors concluded that the government and private purchasers of health care could increase use of care management processes by offering external incentives to improve health care and by helping physician groups improve their clinical electronic information capability.
Professional associations are becoming involved. Most speciality societies have addressed the barriers and benefits to members of electronic clinical data sharing. The American Academy of Family Physicians, for example, has taken the lead in an initiative to promote inter-operable EHRs (American Academy of Family Physicians 2004). Designed mainly for solo or small-group practices, the model recommends vendors who have agreed to make an EHR capable of transmitting Continuity of Care Records via a secure Internet connection.
Health systems, academic medical centres, community hospitals, and home health agencies are building information systems that link multiple providers. A number of well-known health systems and academic medical centres, such as the LDS Hospital in Salt Lake City and Brigham and Women's Hospital in Boston, have developed their own integrated electronic clinical record systems (Doolan, Bates, and James 2003). A number of hospitals in Indianapolis use the Regenstrief Medical Record System (McDonald et al. 1999).Geisinger Health System (2004) in central Pennsylvania has created a fully integrated medical record with electronic communication with the primary care physician that also is accessible to the patient and the family caregiver. Partners Health Care has created a clinical data repository that allows data to be shared across several hospitals in Boston as well as community health centres and community-based physicians (Partners Health System 2004).
Community hospitals are taking advantage of generalised software systems that provide direct clinician order entry, results reporting, and an EHR, as well as administrative functions. One vendor reports that it has implemented its basic system in over a quarter of the country's 6,000 hospitals (Meditech 2004). This basic system allows for the creation of an EHR within a hospital. In addition, several hospitals are migrating into ambulatory settings by integrating the medical record in the physician's office into the hospital's medical record. Future plans would include in the record any information collected in the patient's home and other community settings, thus enabling the coordination of care across settings.
Health Plans and Insurers
Insurers, managed care organisations, self-insured corporations, and self-insured unions are major purchasers of care and are committed to providing high-quality and less expensive health care. A leading example of data sharing from the managed care sector is the Clinical Information System (CIS) that Kaiser Permanente is implementing throughout its organisation (Kaiser Permanente 2003). Kaiser's EHR includes demographic and benefit data, pharmacy data, and transcribed reports such as radiology, discharge summaries, history and physical examinations, operative reports, consultations, surgical pathology, cytology, and outpatient laboratory results. The clinician can use the system to confer with other providers, thereby better coordinating the patient's care. Eventually, patients will be able to interact online with their medical team. An evaluation of the pilot phase of the outpatient system found that the clinicians’ acceptance was high, with 95 percent of visits entered and 70 percent of prescribing and laboratory and radiology test ordering on the system (Chin and McClure 1995).
Disease Management Companies
Disease management companies use electronic tracking systems to improve care by monitoring the condition of patients assigned to them by insurers. Typically, insurers employ disease management companies to manage their patients with chronic diseases in an attempt to keep the disease under control so as to prevent the recurrence of symptoms and the use of expensive health services. Nurses contact the assigned patients to monitor their symptoms and periodically consult with the patients’ physicians regarding the appropriate care plan. If the disease management companies’ EHRs were able to link with the physicians’ EHRs, the nurse managers, primary care physicians, and specialists could better coordinate their care.
Federal Health Programs and Agencies
Medicare spends more than two-thirds of its funds providing fee-for-service medicine to people with five or more chronic conditions who see an average of nine ambulatory clinicians during one year (Partnership for Solutions: Better Lives for People with Chronic Conditions 2002b). Pay-for-performance models are being tested in which the payer offers an incentive to the care provider to improve quality by reimbursing a set amount for each complex patient when the physician provides evidence that certain standards of care have been met (Centres for Medicare & Medicaid Services 2003). This model is similar to a pay-for-performance model implemented with the sponsorship of Bridges to Excellence, a nonprofit organisation of employers, providers, and health plans (Bridges to Excellence Working Group 2004). Several innovations in reimbursement from CMS are in the demonstration phase, and the Medicare Prescription Drug, Improvement, and Modernisation Act of 2003 provides for more demonstrations of reimbursement systems and EHRs to enhance coordination of care (U.S. Congress 2003). The Agency for Health Care Research and Quality (AHRQ), which has been the lead federal agency in supporting research on information technology (Fitzmaurice, Adams, and Eisenberg 2002), will be awarding $50 million in grants to “support organisational and community-wide implementation and diffusion of health information technology [HIT] … and to assess the extent to which HIT contributes to measurable and sustainable improvement in patient safety, cost, and overall quality of care” (Agency for Healthcare Quality and Research 2003).
Communication systems can be integrated into the closed systems just described, in which there is a centralised authority. In open settings, which are typical of most health care in the United States, the challenge is greater. Possibly the most comprehensive approaches to inter-operable EHRs are the regional initiatives that attempt to enrol all providers within a given geographic region. If successful, they will be able to offer an integrated clinical record with the exchange of clinical data among providers caring for a defined population. The Regenstrief Medical Record, for example, evolved from a single hospital-based clinical information system to a system that currently uses the Internet to connect all five Indianapolis hospital systems and a total of 11 geographically separated hospitals.
An example of a regional solution explicitly designed for clinical data exchange is currently being used in Santa Barbara, California. This project, developed over four years with $10 million in financial support from the California Health Care Foundation and the Robert Wood Johnson Foundation, was designed to improve the quality, clinical efficiency, and safety of health care by making inter- and intra-organisational, patient-specific information more readily available at the point of care (California Health Care Foundation 2004). In 2004 the data exchange was composed of 12 health care organisations, with a central policy-making council, technical and clinical advisory committee, and data alliances. Data alliances are multiple provider organisations that agree on and coordinate data-sharing goals and technical standards and business rules to facilitate implementation. The number of participating physicians in the data exchange will be critical to determining the value of this model.
Remaining Stakeholder Concerns and Possible Solutions
Before EHRs that can connect with other health providers will be widely adopted, a number of policy issues must be resolved. In this section of our article, we summarise the concerns and possible solutions from the perspective of patients, physicians, institutional providers, and payers and examine those issues that must be resolved in order for these systems to be implemented broadly.
Patients with multiple chronic conditions must recognise that their care will be better coordinated if information is shared with all their providers. The consumers’ interest in quality of care—specifically, the reduction of adverse drug events, unnecessary hospitalisations, and unnecessary tests—may become the primary motivation to improve electronic communication among clinicians. The public's concerns may persuade the purchasers of care to make these changes. The challenge will be mobilising the 60 million Americans with multiple chronic conditions to demand the coordination of their care.
Health providers, policymakers, and payers who have a high stake in improving the medical care system in the United States recognise that EHRs offer the possibility of improving the quality of care through better coordination while controlling health care costs. With new emphasis and priority from the federal government, the public will be made aware of these benefits. Large closed health systems have successfully implemented inter-operable electronic health records and are learning what is effective as well as where different approaches are needed. Nonetheless, there are significant barriers to adopting an EHR, particularly by those physicians who have the major role in terms of time and cost invested in implementation. To replicate this success in the larger open health care arena of the United States, we have three suggestions: agreement on a common health record, a geographic governance structure that can offer a common solution for a geographic region, and reimbursement for the costs by payers for health care. These suggestions, aimed at encouraging the use of electronic health records, will improve the quality of care for all patients and greatly improve the coordination of care for the 60 million Americans with multiple chronic diseases who see many different physicians.
The time has come for medical practices that have not yet converted their paper files to Electronic Health Records (EHR) to do so. Those practitioners who are unable to demonstrate meaningful use, as it is defined by the Health Information Technology for Economic and Clinical Health (HITECH) Act, will experience reductions in their reimbursement claims to Medicare and Medicaid.
Benefits of using EHR’s
According to the health information technology website provided by the federal government, there are a number advantages to practitioners who use EHRs. Some of those include:
1. Quality of patient care is improved: The patent’s information is found in one place and accessible to all care providers relevant to the particular patient. Electronic referrals make it faster for necessary follow-up care to be performed and the doctor to whom the patient has been referred has immediate access to the patient’s information. Medical errors are reduced and prescribing of medications is more reliable.
2. Patients have more participation in their own care: Patients are able to access their own medical records and get test results as soon as the results are completed and entered into the EHR. Patient portals allow patients to interact online with their health care provider. This may result in earlier diagnosis and treatment.
3. Provides for more accurate diagnoses and treatment: When a physician has access to the most complete and up-to-date health care information, as is available with EHRs, it results in more accurate diagnosing. The records will include alerts to a patient’s allergies and any adverse interactions with prescription medications.
4. Improves the coordination of patient care among providers: As technology has advanced, and medical treatments improved, patient care often involves teamwork among several practitioners, such as primary care doctors, specialists, physical therapists, nurses, ancillary health care providers and pharmacists. Using EHRs allows each provider to have immediate access to care provided by other practitioners and reduces fragmentation of piece-meal information. It also reduces medication errors and repetition of tests.
5. Increases the efficiency of the medical practice and cuts costs: Major cost savings are found in decreasing the amount of paperwork. There is a reduction in duplication of testing. Using EHRs to send prescriptions saves time. Money is saved by not needing medical transcription services. Paper files to do not have to be managed by retrieving them and re-filing them. EHRs provide for more accurate billing and coding to reduce problems with reimbursement claims.
You may have seen advertisements, or may already have been contacted by people who’ve promised to help you figure it all out so you can get your share of the stimulus money. Be wary. The truth is that the Obama administration is still defining many essential elements of the Health Information Technology for Economic and Clinical Health Act (HITECH), and full details about the exact reimbursement process will not be known until the fourth quarter of this year, at the earliest.
The difference is in the details
There is one quick way to tell if you’re dealing with a consultant or a reseller. A reseller’s services should be free to you because the vendor is picking up the tab by paying the reseller a percentage of the sale, or some other pre-arranged fee. You know in advance that a reseller is going to steer you toward a particular product, and you can thus take what they say with the same healthy dose of skepticism that we apply to information we receive from drug reps.
On the other hand, if you are paying for services and recommendations, then you are dealing with a consultant who should be giving you unbiased advice. Unfortunately, a good number of consultants accept fees from doctors but then also receive referral fees from vendors for sending them potential clients. These payments may be in the form of cash, discounted hardware and software, or anything else of value.
The wild frontier
You need to ensure that the information you receive from these “experts” is unbiased and based on the reasonable approach of matching your practice’s needs with the available solutions. A few key steps could save you tens of thousands of dollars in hardware and software expenses, not to mention the frustration of being cajoled into purchasing an overpriced and unusable EHR that you’ll regret later:
• When considering an EHR consultant, ask them pointblank if they have any relationship with one or more vendors, and ask exactly how those relationships work.
• Ask the consultant how many practices of similar size and specialty they have helped in the past, and get at least three different practice names and contact information to confirm that they were pleased with the consultant, would recommend their services, and would use them again.
• For smaller practices, be especially wary of consultants who also sell IT hardware and/or technical support. In my experience, IT consultants tend to recommend significantly more complex (and expensive) hardware and software than is necessary for the average small medical practice.
The third point deserves a bit more discussion, since many of the consultants in the EHR space also provide IT services and sell computers, servers, and other hardware. The main problem with hiring an IT consultant for guidance is that all too often these technologically -minded people push equipment and policies that are significantly more expensive and complex than is reasonable to run a small practice.
In my experience as an EHR vendor, all too frequently when an IT consultant is used, the practice ends up not only spending much more on hardware than my non-IT-consultant practices, but they have much less of an understanding of their system and thus an inability to troubleshoot issues that arise from time to time. In fact, Amazing Charts (my EHR company) recently raised prices for additional providers because we found that larger practices tend to have overly complex technology infrastructures based on the recommendations of their IT consultants. These systems take more time and energy to troubleshoot, and much more frequently, hardware and network issues are the source of the difficulties that lead to downtime.
Everybody does it, right?
When a consultant does recommend a specific product, whether an EHR system or anything else, do some online research to find out what others have to say. The American Association of Family Physicians has a good site for researching EHR software (ie, the Center for Health IT). Message boards can be another useful research resource, if you have time to sort through all the garble.
The most important take-away from this month’s column is to make sure that your independent EHR consultant is not actually shilling for someone else. Get it in writing so you have some legal recourse if you make a purchase and have buyer’s regret a few months later
New research, published today in Health Affairs, from the Office of the National Coordinator for Health Information Technology (ONC) show that health information exchange (HIE) between hospitals and other providers jumped 41 percent between 2008 and 2012.
The research – authored by National Coordinator for Health Information Technology Farzad Mostashari, M.D., and ONC researchers – indicates that six in 10 hospitals actively exchanged electronic health information with providers and hospitals outside their organisation in 2012.
The research suggests that electronic health records (EHRs) and health information organisations (HIOs) are complementary tools used to enable health information exchange. Stage 2 Meaningful Use, which requires eligible hospitals to exchange with outside organisations using different EHR systems and share summary of care records during transitions of care, can help accelerate hospital use of HIE as a means to enhance care quality and safety.
“We know that the exchange of health information is integral to the ongoing efforts to transform the nation’s health care system and we will continue to see that grow as more hospitals and other providers adopt and use health IT to improve patient health and care,” said Dr. Mostashari. “Our new research is crystal clear: health information exchange is happening and it is growing. But we still have a long road ahead toward universal interoperability.”
Highlights of the new study show:
Electronic health records save lives by collecting patient data in one place. Artificial intelligence takes it a step further by calling on the expertise of multiple doctors.
While I had heard that almost 400,000 Americans die each year because of medical mistakes, in a recent article Forbes contributor Dan Munro underscored that volume when he asked readers to imagine the largest commercial aircraft -- an Airbus A-380 -- crashing every day for a year: The number of passengers who would perish aboard those imaginary crashes compares to the number of patients really dying annually in our hospitals due to blunders.
People who want nothing to change usually dispute the number of deaths. For the sake of argument, let us assume the actual number could be represented, then, by one crash every four days. Even then, surely it is worthwhile trying to figure out how to prevent these errors.
Certainly, procedural failures or pure accident causes some errors but incomplete or incorrect information about the patient is at the heart of a large percentage of these mistakes.
As Munro points out, a major problem is that the current healthcare industry is incentivized by revenue and profits -- not safety and quality. Therefore, as newly re-elected Florida Governor (and former healthcare CEO) Rick Scottsaid at a recent meeting to discuss cutting costs in healthcare, the industry has been unwilling to voluntarily reduce profits. Since safety and quality using current methods would be expensive and slash profits, perhaps electronic health records (EHRs) and health information technology (HIT) could accomplish the goals of all stakeholders.
EHRs can maintain patients' complete medical histories, along with all known allergies and medications. The record should travel with patients, no matter where they go for treatment. Doctors do not have to rely on the patient's fallible memory at every encounter. The record speaks for patients, even if patients are incapacitated for any reason.
We must recognise that doctors often face points of no return -- and patients get no second chances. Choosing the right medicine or treatment is frequently a game of probabilities. Choose the right medicine and the patient will live. Choose the wrong one and the patient will die. This is why even the most qualified doctors often seek second or third opinions before embarking on a risky treatment plan. Doctors have told me countless stories about their ability to save patients because a complete EHR was available. In these cases multiple doctors were able to view the same information at the same time, often while residing thousands of miles apart. They collaboratively agreed on the best option -- and saved the patient's life.
EHRs also facilitate artificial intelligence. A patient's medical history often is full of reams of data; manually winnowing through that information is a daunting task. Today, teams of top doctors help develop artificial intelligence systems that can quickly determine if a proposed medicine, food, or medical procedure will likely cause the patient greater harm than good. This will reduce a large number of medical mistakes.
There is no cause for concern. Decisions suggested by artificial intelligence systems developed by top-notch doctors likely are more accurate than decisions made solely by humans. Watch Vinod Khosla discuss this fascinating issue. All doctors are not created equal. As Khosla pointed out, studies show that if you give the same data on a patient to a random group of 10 doctors and ask them if surgery is recommended, half will choose surgery while the other half will choose not to perform surgery.
If artificial intelligence systems are built using the medical minds of the doctors that choose the right answers, these technological solutions sift through an incredible amount of data and provide more medically reliable recommendations. Of course, a human doctor still makes the ultimate decision. However, the doctor has the benefit of a large amount of data analysis and is much more likely to make a decision based on complete information, not incomplete data.
Perhaps EHRs plus AI will save many more lives and dramatically reduce medical errors without increasing costs too much.
With the federal government spending tens of billions of dollars to push healthcare providers to install electronic health record systems, health information technology has been at the forefront of innovation in the healthcare industry for most of the past decade.
Being a caregiver is hard, but health IT can help caregivers manage a loved one’s care. From tracking multiple medications to having all your health information in one place, health IT and new mobile technology are proving to be valuable resources to patients and people like me, those of us who take care of a loved one.
For starters, I had no information about my mother’s medical history—she was the superwoman and glue that held our household together. So when I was asked about family history and who her primary care physician was, her ER nurse and doctor were met with my tears and endless blank stares.
How was I supposed to know?
The healthcare system did not care that I didn’t know and my level of readiness was not their concern. My life was transformed and from that day forward, I was dubbed caregiver—care coordinator and documentarian extraordinaire for my sweet mother.
The life of a caregiver is not glamorous—no one aspires to be a caregiver because it usually signals something has gone terribly wrong. More than 90 million caregivers across the U.S. provide nearly $450 billion worth of unpaid care annually. Many of these caregivers are full-time workers. Younger Americans between the ages of 18 and 29 make up 36% of the family caregiver population.
As a family caregiver it means the decisions you make have a direct impact on your patient’s daily comfort and their overall quality of life. We perform both complex medical and nursing services like medication management and wound care for our loved ones, but also the mundane tasks like bathing. I’m frequently responsible for coordinating her care and making sure the proper pieces of health information flow between her primary care doctor and the myriad of specialists.
I’ve essentially become my mother’s medical home, making sure that she followed up with the home care agency when she was discharged from a hospital-stay, or bringing a summary of the last doctor’s visit from her primary care physician in Maryland to her nephrologist in Washington, D.C.
There are also a number of co-morbidities associated with a disease like ESRD, so making sure she has an assigned specialist to monitor her heart, vision, nutrition, etc. was something I needed to stay on top of. Yes, she had a primary care physician, but the reality is, as a caregiver I’m much more sensitive to her needs.
Health Information Technology has been an extremely useful tool in managing/coordinating my mother’s care. The road wasn’t easy, the learning curve was steep, but I’ve been using a number of mobile health applications to help manage my mother’s overall wellbeing a little better. I am much more efficient and have learned to save a lot of time.
With the help of these different health applications, I can compile the summary notes from her visits and document questions I have about her care so that when she does need to see her doctor, the questions are well-informed and very specific. The number of readmissions due to her kidney disease and diabetes has decreased dramatically—from 14 readmits in 2011 to two only admissions so far this year. When healthcare professionals in the hospital can’t seem to talk to one another or share notes, I at least have all the up-to-date insurance information, prescription lists, and her physician contacts centralized in one place.
The other benefit I’ve experienced is with the coordination of her social services. I’ve found there’s a disconnect between the health component and human services. My mother’s diagnosis and disability meant she had to stop work. The best way to describe the coordination of social services, pre-health IT, is “baptism by fire” (no kidding). However, with mobile apps, like Blue Button, I’ve been able to do some of the financial reconciliation on her Medicare claims data, often required for some of the social services offered at the state level.
Health Information Technology can be fun (really). Health IT has helped me become more efficient—I’m now using a number of food apps to get ESRD-friendly recipes (we have to be mindful of things like acid, and potassium among other things). I’ve also downloaded applications that provide us with at-home exercises/activities.
It’s been a rewarding experience as an ONC team member. I’ve had the opportunity to use the tools and better understand the policies that are digitizing health care in a way that offers patients (and their families) better access, better health and lowered costs. As we continue our work on the implementation of meaningful use stage 2, aligning our program work with patient-centered models like ACOs and the medical home.
The importance of end-user training cannot be overemphasised for a successful electronic medical records system implementation. While this information is nothing new, administrators and providers may still find it difficult to determine when EMR training has been effective. Fortunately, there are performance indicators and measurable outcomes that can help you determine whether or not an EMR training system has worked for your practice.
There is well-documented evidence of EHR systems positively affecting medical practice structure and processes following an effective implementation. In this way, coding accuracy can be a very good indicator of successful training of end users such as providers and their staff. Trends in inaccuracies, such as incorrectly coded patient histories, medication dosages, and more can reflect gaps in training where users need additional instruction or support.
Naturally, there will always be some variation in workflow between providers and staff based on personal preferences and style. However, significant variations in identical processes (i.e. medication orders, pharmacy refill requests, or charting items) can be evidence of a critical training gap. One common contributor to such variations is an updated training curriculum, either offered internally or through an EHR vendor, resulting in providers who received two different training programs for the same system. Such differences are a good indicator of where training gaps can be closed.
One critical and easily quantifiable indicator of successful EHR implementation is billing. A successful training program will result in proper and correct coding from billing staff, along with confidence and competency navigating coding regarding insurance, office procedures, Medicare and Medicaid variations, and more. Quantifying billing errors before, during, and after “go-live” can help a practice optimise its EHR system and demonstrate palpable benefits and returns from a successful implementation.
One of the many benefits of adopting an EHR system is increased efficiency and productivity, which is best fostered by system acceptance. Acceptance indicators include feedback from the staff and providers themselves and affect overall morale and EHR utilisation. Once providers and staff are receptive and committed to the EHR system, efficiencies can be observed and quantified through waiting room times, technician workup duration, and other measures. These are helpful indicators to determine the overall efficiency of a medical practice, and can also reflect the success of an end-user training program for the records system.Applying EMR Training Indicators to Optimisation
Following EMR training indicators is a great way to ensure that end-user training has been effective. But there are other benefits to these analyses as well, and tracking training outcomes can become a significant part of optimisation. Following the implementation of an EHR system, optimisation is critical to ensure that you’re getting the most out of your records system.
At ZH Healthcare, we understand that a successful EHR implementation relies on confidence and competency from all providers and staff. That’s why we offer unique, tailored training for our Health IT as a Service (HITaaS) systems like BlueEHS, and are readily available with dependable support before, during, and after implementation. Contact us today to learn more about our medical records training and support services, and discover how we can transform the way you do EMR.
Commitment to success, engagement from all concerned and a shared interest in continuing improvement can take you far.
Kenneth G. Adler, MD, MMM
Previously I wrote a “how-to” article describing how to achieve a successful electronic health record (EHR) implementation.1 I sorted the dos and don'ts of implementation into three categories that I called team, tactics and technology, and focused on the teamwork, knowledge and skills needed to succeed. I still find that paradigm useful.
In the past few years, however, I've been able to observe a number of EHR implementations around the country. In addition to my full-time family medicine practice, I work as an IT medical director for a large primary care group in Arizona that to date has implemented an EHR in 23 unique office practices. Previously I consulted for the now inactive DOQ-IT (Doctor's Office Quality Information Technology) program, which was designed to help small practices select and implement EHRs, and I now consult independently around the country on new and troubled EHR implementations.
The new lesson I've learned is this: Attitude matters. A lot. It may not quite be “everything,” but the right attitude will help bring you far on your EHR journey.
Implementing an ambulatory EHR is a complex, challenging process. One can surf the Internet and find poorly substantiated claims that anywhere from 10 percent to 50 percent of EHR implementations fail. Often these claims are purely speculative, are based on events that occurred many years ago or really refer to inpatient EHR failures. Limited research has been done in this area, and what has been done has been poorly designed.
My opinion, based on observation and conversation with others involved in health IT, is that ambulatory EHR implementation failures, as defined by never using or ceasing to use all of the purchased software, are quite unusual. On the other hand, not fully using purchased ambulatory EHR functionalities, or using them ineffectively or inefficiently, is quite common. I've observed sites that still have paper charts after years of being on an EHR, despite having scanning capability. I've seen sites where some doctors use all the functions of an advanced, comprehensive EHR effectively, while their partners refuse to do anything on it but review data. I've seen sites where even active problem lists aren't completed, much less past medical, surgical, family or social history lists. To my surprise, I've seen e-prescribers who don't bother to update or complete their medication lists. And frequently, I've seen sites where health maintenance functionality is ignored.
These commissions and omissions do not necessarily mean that an EHR implementation has failed, but they do mean that the EHR ends up not being used anywhere close to its maximal effectiveness. They are what can be called “partial implementations” rather than successful ones.
Principles of success – the five fold path
Buddhism may have an eight fold path, but the path to EHR nirvana (or contentment, at least) is only five fold. So the good news is that it's easier to successfully implement an EHR than to become a Buddhist monk. The first three elements on the EHR path are really attitudes – full commitment, extensive engagement and the desire to see continual improvement. The fourth element is having the necessary resources. The fifth element is having the requisite knowledge.
With regard to the first three elements, not only must your implementation team and organisation leadership share these attitudes, but you must also be able to promote them throughout your organisation.
Commitment means the willingness to invest the time and money needed to make the implementation successful – to do whatever it takes. Doing so really needs to be viewed as a long-term investment. Fortunately it's an investment that will likely pay bountiful dividends if done well.
As a successful implementer, you will need to commit adequate capital both for quality software and hardware. You will need to commit to spending a lot of time planning every step of the process. And you will need to commit to adequate training – both initial and ongoing – which costs both time and money. Too often practices skimp on initial training, leaving users with limited skills. Even more often, practices offer no ongoing training, not realising that the skills to become expert rarely come after just two, four or even eight hours of initial training.
Why are successful implementer committed? Hopefully it's not just because they fear failure. I suspect that they truly believe that their EHR will fundamentally improve the quality of the care they provide and the efficiency of their practice.
If you are unconvinced of that and aren't sure the effort is worth it, I encourage you to pause. Seek out leaders of successful implementations and see what they've done and how their practices are running. Hopefully that will inspire you.
Many implementations suffer from a lack of end-user engagement, particularly physician engagement. The implementation process is viewed as a burden, and physicians typically want to delegate it to their administrative staff. That may seem reasonable. Physicians should focus on seeing patients, after all. But this isn't financial software. It affects every aspect of how physicians practice their craft, and if they aren't involved in the selection and configuration of the software, they are likely to resist and resent the behaviour changes the software demands. Plus the decisions made in selection, setup and new workflow design are likely to be of lower quality than they should be, absent input from physicians and other end users.
Clinical staff members tend to follow the example of the physicians with whom they work. If physician engagement is low, staff engagement will likely suffer as well.
You can increase engagement several ways. First, insist on involvement of your end users, especially the physicians, from the start of the implementation or, better, from the start of the software selection process. Second, offer frequent, informative and even repetitive communication. Third, through your communications, help people set reasonable expectations. Finally, conduct your decision-making process in a fair and open manner.
Those who implement EHR systems successfully believe that whatever they are doing now can be improved. They aren't satisfied with the status quo, and they desire to try new things – if it will help them achieve their aims. They are flexible, and although they may not like change, they accept it as necessity. Put in management lingo, folks with this attitude are believers in and practitioners of continuous quality improvement. I'm not sure how people acquire this attitude, but if you believe that your practice is as good as it can get, I challenge you to look deeper.
Three resources are critical – quality software, strong vendor support and a sound technical environment. Yes, there is a difference in quality between various EHR products. And, yes, some vendors provide better support than others. So take your time during the selection process. It can make a large difference. Likewise, be sure you've invested in appropriate hardware, bandwidth and technical support. If you've outsourced the technology component of your EHR by using an ASP (application services provider) or SaaS (software as a service) arrangement, make sure that the vendor you hired has a proven track record for high network availability and responsiveness in correcting technical glitches.
Knowledge is important, but the easiest of the five elements to acquire. Your vendor should be a key resource. Pay close attention to the vendor's advice about what it takes to implement the system successfully. After all, the vendor has seen lots of implementations. You will probably see only one. You may also find the implementation article that I wrote in 2007 helpful.
An acronym to remember
Here's an acronym that might help you remember the five principles of a successful EHR implementation. CRIKE. (Imagine that you are in the northern reaches of Australia and unexpectedly encounter a ravenous, twelve-foot crocodile. You start to say “CRIKEY, MATE” – but just don't have time to finish.) Remember: Commitment, Resources, Improvement, Knowledge and Engagement.
Successful implementation is a moving target. Once you master one set of functionalities and workflows, new ones are likely to come along. Having strong individual and organisational commitment, end-user engagement, desire to improve, resources and knowledge will help lead you to turn your EHR into an awesome, indispensable tool that helps you do what you do best: take care of patients.
The Obama administration on Monday night announced a new agreement with major hospital systems and leading electronic health record vendors to make it easier for patients to access those digital records, reduce barriers to sharing the information between health providers, and standardise technology that would better allow communication across the platforms containing patient data.
The agreement involves vendors that provide 90 percent of the electronic health records (EHRs) to U.S. hospitals, as well as health-care systems in 46 states, including the nation's five biggest private health systems.
More than a dozen professional health organisations also have signed on to the agreement, the latest step in the transition from a system that once relied on paper to document a patient's medical history to one that relies on electronic bytes for that task.
The pact, which has three main commitments, represents an effort by the Obama administration to speed up an ongoing effort to make digitised records more effective in helping treat patients and improve portability of the electronic data.
Despite that effort to date, EHRs are not always readily accessible, not always usable in the form that providers receive them and not always easy for the patient to understand, said Dr. Karen DeSalvo, national coordinator for health information technology at the U.S. Health and Human Services Department.
DeSalvo said the pact "reflects a shift in the way that [EHR] developers and providers are willing to do business."
Under the agreement, the participants commit to help patients "easily and securely access their electronic health information, direct it to a desired location, learn how the data can be shared and used, and be assured the data is being effectively and safely used," according to a fact sheet distributed by HHS.
Another commitment is to not "block" information, allowing health providers to share patient records with other providers and the patients themselves, and not unreasonably interfere with such sharing.
The third commitment is to implement federally recognised, national interoperability standards, policies and practices for EHRs.
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"These commitments are a major step forward in our efforts to support a health-care system that is better, smarter and results in healthier people," said U.S. Health and Human Services Secretary Sylvia Burwell.
She revealed the agreement during a speech Monday at the Healthcare Information and Management Systems Society's conference in Las Vegas.
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In prepared remarks, Burwell said that "we have made tremendous progress to bring health care into the 21st century," noting that in the past six years there has been a dramatic increase in the adoption of electronic health records, with about 75 percent of all doctors now using them, along with almost every hospital in the country.
"But we still have work to do to get the real value of this information for providers and consumers," Burwell said. "As we look at where our current way of doing things falls short, it's in three areas."
Referring to those areas, Burwell said that "consumer access remains a challenge."
"It's great to have an electronic record, but if that record can't be easily accessed by doctors and patients because of clunky technology, then we aren't consistently seeing the benefit," she said.
Burwell also said that digital patient records are "still too often knowingly or unreasonably blocked" by hospitals or doctors, either because of business practices "or misunderstanding" of the federal health information privacy law.
And, she added, "Without agreement on a common data 'alphabet,' our technology is stuck speaking different languages."
Mary Paul, vice president in the information services division of Ascension, one of the participants in the agreement, said that "interoperability" is "core to the goal" of having providers connect with each other to care for their patients. (Ascension is the largest nonprofit health system in the U.S. and the world's largest Catholic health system.
Paul said the development of EHRs has been "a significant journey to go from a process where you collect information in paper form from many different sources."
But she noted that even with the rise of EHRs, "there are a lot of interests to coordinate ... a lot of different parties that really require come coordination."
"I think when the community of providers and suppliers come together to promote the same set of standards, I do think that will make change," Paul said. "What we're trying to do is speak with a single voice, and I do think that's important."
Another participant in the agreement is EHR vendor Athena health. The company's director of government and regulatory affairs, Stephanie Zaremba, gave a lukewarm assessment of how significant the agreement is, at this point.
"Signing this pledge must not be regarded as a significant accomplishment or milestone for any stakeholder," Zaremba said.
"Athena health is and always has been committed to the goal of achieving the same ubiquitous information exchange that is commonplace in every other sector of the information economy," Zaremba said. "We have signed the latest government-orchestrated 'private sector commitment to interoperability' and are once again on the record supporting the broad goals of achieving connected care."
"The problem, however, is that one would be hard-pressed to find a stakeholder in our industry that is not already rhetorically committed to those goals," she said. "We are at the point as an industry where we need more action and fewer words. We want to see the [Office of the National Coordinator for Health Information Technology] take a step back and allow the private sector to continue its progress around a 'bottom up' approach to interoperability, not a top-down approach centred around the low bar of federally recognised standards."
Premier, a health-care performance improvement alliance of 3,600 hospitals and 120,000 other medical providers, is another participant in the agreement.
Blair Child, senior vice president and spokesman at Premier, said,"Members of the Premier health-care alliance are pleased to join other stakeholders that have pledged to voluntarily implement interoperability and public access standards in health information technology."
But he also said that, "While the pledge is a positive statement of commitment, we continue to believe that legislation is important."
Child added, "We support a public rating system of vendors' technology based on its performance on outcomes measures of usability, functionality and interoperability. We also support the granting authority to investigate and fine vendors who engage in information blocking."
Electronic health records directly benefit the health care system and society on a whole—they can cut costs and collect data—but currently the greatest benefit is to you. They provide extra safety measures and give you easier access to your doctor and medical information, says Corley.
Electronic records allow you to access your health information from a smartphone, tablet, or computer—no matter where you are. This can come in handy for information that previously may have taken several phone calls to discover. For example, if you forget how to take the medication that your doctor prescribed, you can go online to access your doctor’s notes about how to take it, says Corley.
It’s not unheard of for doctors to misunderstand, mistype, or otherwise forget a piece of health data. With electronic records, you can check to make sure all your information is correct. “There are a lot of opportunities, if people have a second pair of eyes on their medical information, to reduce the potential for errors as a result of prescribing,” says Siminerio. As an added bonus, electronic records are getting people involved in their health, says Myrie. “It’s enabling and empowering patients in a new way so they can have access to their information,” she says. “They can review it and distill it at their own time and own pace.”
One of the requirements for government certification for an electronic medical record system is that it must incorporate an online patient portal available for people to easily access their health information. Portals serve as gateways to your test results, current medications, and doctor’s notes. Log on to your provider’s patient portal to schedule appointments, e-mail your doctor, pay your bills, and get health maintenance reminders.
It’s helpful for your doctor to have access to your medical records from anywhere, particularly in emergency situations. Lizerbram tells the story of an ER doctor’s phone call to a primary care physician who was out of town at a medical conference. The emergency room doctor needed medical information about a patient—and fast. The primary care physician was able to pull up that patient’s history on his iPad and give the ER doctor the information he needed. “The people caring for a patient don’t have to make decisions in a vacuum,” says Corley.
In an ideal world, all electronic health records would talk to on another—imagine a single, secure site fed data from all of your health care providers’ electronic record systems. While not all electronic health records are able to communicate with each other at this time, the goal is for all of your health information to be in the same place, where everyone involved in your care—such as your primary care doctor, specialists, the pharmacy, hospitals, and urgent care centers—can see your complete history. In lieu of that, you can download your medical records from one doctor to take to a different doctor who doesn’t have your full medical history. “We see this as a collaboration tool,” says Myrie.
This feature can help the doctor and office staff keep track of when you are due for preventive services, such as an annual dilated eye exam and immunisations. Lizerbram says one doctor’s experience with maintenance reminders underscores their importance. “The reminder prompted the doctor to set the person up for a colonoscopy,” says Lizerbram. “It turned out the gastroenterologist found the patient had stage 1 cancer of the colon, which wouldn’t have been diagnosed until symptoms would have appeared much later.” As a result, that patient had surgery to remove a portion of the bowel and was cancer free without chemotherapy.
Electronic records can quickly scan the medications a person is taking and determine if there are any potential drug interactions or allergies that could be a problem. “It would be very hard for a physician to keep track of all those interactions,” says Corley, “where the computer can quickly do it.”
“You can take even what’s called ‘big data’ out of the EHR,” says Lizerbram. For example, one study reported in Health IT Outcomes looked at the laboratory results of over 11 million people, and found that a million had diabetes but had not been diagnosed. “You could never get that type of data without an electronic health record supplying the data for some organisation to research and review,” he says. Doctors could do this on a smaller scale in their own practices, too. They could tell the system to run a report for everyone with an A1C over a certain marker, which may help them identify patients with undiagnosed diabetes. There is also great potential for this data to look at a broader population of people than you’d find in a research study, which can provide better safety and efficacy information, says Corley.
Health Care Savings
The greater efficiency and quality of care that’s brought about by using electronic health records may translate to cost savings for the health care system as a whole, says Lizerbram. The information exchange that occurs with electronic records can help eliminate duplicate tests at various doctor’s offices, which can rein in costs. And maintenance reminders can catch disease early, so multiple surgeries and expensive medications may not be necessary down the road. But the savings aren’t limited to the health care system. Corley says that, by helping your doctor prescribe the medications your insurance covers, electronic records may save you money, too.
A certified EHR must:
A certified EHR is an EHR that’s demonstrated the technological capability, functionality, and security requirements required by the Secretary of Health and Human Services and has received certification by the Office of the National Coordinator (ONC). This certification is strictly enforced, and EHR vendors have even had their certification revoked for noncompliance.
Why does a certified EHR need to meet Certification Criteria by CMS and ONC?
The Centres for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) have established standard certification criteria for electronic health records (EHRs).
Why does a certified EHR need to store data in a structured format?
Structured data allows patient information and data to be captured and shared efficiently, easily retrieved and transferred, and it allows the provider to use the EHR in ways that can aid patient care.
Why does a certified EHR need benchmarks to help improve care?
Quality of patient care remains at the forefront of CMS initiatives. CMS asks providers to use the capabilities of their EHRs to achieve benchmarks that can lead to improved patient care or else face potential penalties.
Why does certified EHR software need to provide all functionality and security?
Certified EHR software and EHR systems give assurance to purchasers and other users that an EHR system or module offers the necessary technological capability, functionality, and security to help them meet CMS criteria. Certification also helps providers and patients be confident that the EHR software and EHR systems they use are secure, can maintain data confidentially, and can work with other systems to share information.
Why does a certified EHR need ONC Certification?
The ONC-ATCB 2014 certification program tests and certifies that Complete EHRs meet all of the 2014 criteria and EHR Modules meet one or more, but not all, of the criteria approved by the Secretary of Health and Human Services (HHS) for either eligible provider or hospital technology. Practice Fusion is ONC-ATCB 2014 compliant and is certified as an EHR Module in accordance with the applicable certification criteria adopted by the Secretary of Health and Human Services (HHS). Drummond Group Inc., an Office of the National Coordinator (ONC) Authorised Testing and Certification Body (ATCB) certified Practice Fusion’s EHR system.
Why is a certified EHR needed to participate in requirements for CMS and EHR incentive programs?
To qualify for the CMS incentive programs you must use an EHR that is certified specifically for the EHR Incentive Programs. Certified EHR technology gives assurance to users that an EHR system or module offers the necessary technological capability, functionality, and security to help them meet the meaningful use criteria. Certification also helps providers and patients be confident that the electronic health IT products and systems they use are secure, can maintain data confidentially, and can work with other systems to share information.
How to choose the right certified EHR
Choosing the right certified EHR can help you improve the efficiency of your practice and support the overall quality of care for your patients.
Advanced EHR use may lead to significant per patient savings, showing promise for an eventual return on investment, shows a study published in the American Journal of Managed Care.
The study included a retrospective analysis of the National Inpatient Sample (NIS) and the HIMSS Annual Survey to examine patient costs and rates of advanced EHR use.
For the purposes of the study, the researchers defined advanced EHR use as meaningful use. Those that achieved the benchmarks set forth by the Centres for Medicare and Medicaid Services’ EHR Incentive Programs were categorised as advanced EHR users.
“Such criteria for use are based on previous studies that report improvements in quality,” the researchers explained.
“To qualify as a meaningful user and benefit from the related incentives, EHR systems must include electronic prescribing, health information exchange with other providers, automated reporting of quality data, electronic recording of patients’ history (demographics, vital signs, medication and diagnosis lists, and smoking status), created care summary documents, and at least 1 clinical decision support tool.”
After examining the data, the research team identified 550 hospitals for their study, with 104 of them categorised as advanced EHR users.
On average, those 104 hospitals saw a notable drop in per patient costs, with each patient costing $731, or 9.66 percent less than patients treated at other hospitals. Those results take into account patient- and hospital-specific variables.
According to the researchers, such cost savings may be credited to the increased efficiency advanced EHR use may bring.
“Meaningful use requirements are believed to improve the legibility of records, reduce prescription errors, improve adherence to best clinical practice guidelines, improve patient and clinician access to records, and allow exchange of health information,” the research team said. “In addition to gains in quality, EHRs have been predicted to save $81 billion annually through safety improvement and increased efficiency of care.”
Despite these results, the researchers recognise that not all EHR users are seeing cost savings, or return on investment. This may be because they are not utilising all of the EHR features necessary to deliver cost-efficient care.
“The staging model that was used demonstrates that cost savings may not be realised until multiple features are included and implemented,” the researchers explained. “Since EHR systems are complex and costly to implement, it is often a multistage process to adopt and use EHRs.”
“Thus, hospitals must anticipate that the financial savings may not exist until advanced, ‘meaningful’ use is attained,” they continued. “The majority of hospitals have yet to reach the stage of implementation where cost savings are possible, since they are not using advanced EHRs.”
The team also acknowledged the significant up-front costs associated with advanced EHR use, recognising that an initial EHR implementation can run hospitals hundreds of thousands of dollars.
That all said, this data can be used to help build the business case for EHR adoption.
“These cost savings will benefit many third-party payers, hospitals, and patients, and incentives such as those provided through the HITECH Act to promote EHR adoption and use will benefit hospitals,” the research team concluded.
“Since many previous studies have shown that EHRs can improve the safety and quality of care in hospitals, the projected cost savings in this study provides additional motivation and builds the business case for hospitals to make the large investment in adopting and maintaining an EHR system.”
What’s in a word? Or, even one letter of an acronym?
Some people use the terms “electronic medical record” and “electronic health record” (or “EMR” and “EHR”) interchangeably. But here at the Office of the National Coordinator for Health Information Technology (ONC), you’ll notice we use electronic health record or EHR almost exclusively. While it may seem a little picky at first, the difference between the two terms is actually quite significant.The EMR term came along first, and indeed, early EMRs were “medical.” They were for use by clinicians mostly for diagnosis and treatment.
In contrast, “health” relates to “The condition of being sound in body, mind, or spirit; especially…freedom from physical disease or pain…the general condition of the body.” The word “health” covers a lot more territory than the word “medical.” And EHRs go a lot further than EMRs.
What’s the Difference?
Electronic medical records (EMRs) are a digital version of the paper charts in the clinician’s office. An EMR contains the medical and treatment history of the patients in one practice. EMRs have advantages over paper records. For example, EMRs allow clinicians to:
But the information in EMRs doesn’t travel easily out of the practice. In fact, the patient’s record might even have to be printed out and delivered by mail to specialists and other members of the care team. In that regard, EMRs are not much better than a paper record.
Electronic health records (EHRs) do all those things—and more. EHRs focus on the total health of the patient—going beyond standard clinical data collected in the provider’s office and inclusive of a broader view on a patient’s care. EHRs are designed to reach out beyond the health organisation that originally collects and compiles the information. They are built to share information with other health care providers, such as laboratories and specialists, so they contain information from all the clinicians involved in the patient’s care. The National Alliance for Health Information Technology stated that EHR data “can be created, managed, and consulted by authorised clinicians and staff across more than one healthcare organisation.”
The information moves with the patient—to the specialist, the hospital, the nursing home, the next state or even across the country. In comparing the differences between record types, HIMSS Analytics stated that, “The EHR represents the ability to easily share medical information among stakeholders and to have a patient’s information follow him or her through the various modalities of care engaged by that individual.” EHRs are designed to be accessed by all people involved in the patients care—including the patients themselves. Indeed, that is an explicit expectation in the Stage 1 definition of “meaningful use” of EHRs.
And that makes all the difference. Because when information is shared in a secure way, it becomes more powerful. Health care is a team effort, and shared information supports that effort. After all, much of the value derived from the health care delivery system results from the effective communication of information from one party to another and, ultimately, the ability of multiple parties to engage in interactive communication of information.
Benefits of EHRs
With fully functional EHRs, all members of the team have ready access to the latest information allowing for more coordinated, patient-centred care. With EHRs:
So, yes, the difference between “electronic medical records” and “electronic health records” is just one word. But in that word there is a world of difference.
Overview of the EHR
The Electronic Health Record (EHR)– then called the Electronic Medical Record (EMR) or Computerised Patient Record (CPR)– received it first real validation in an Institute of Medicine's (IOM) report in 1991 entitled "The Computer-Based Patient Record: An Essential Technology for Health Care. IOM drove home the idea that the EHR is needed to transform the health system to improve quality and enhance safety.
The following is a list of basic terms you will need to know as you navigate the EHR market:
Potential Benefits of an EHR
Potential Productivity and Financial Improvement
Additional potential benefits may include: population management and proactive patient reminders; improved reimbursement from payers due to EHR usage; and participation in pay-for-performance programs.
Quality of Care Improvement
Job Satisfaction Improvement
Customer Satisfaction Improvement
As more healthcare facilities, from hospitals to private practices, move from paper charts to electronic medical records, the benefits will increase to both practitioners and patients: Electronic health records can be accessed on demand, and can potentially save lives.
Benefits to Patients
Electronic health records contain significantly fewer errors than paper records, according to experts.
Communication between physicians can be greatly improved with the use of EHR, allowing each party full access to a patient’s medical history rather than a snapshot-type overview from a current visit. This access allows for a more in-depth evaluation, and enables doctors to reach an accurate diagnosis more quickly.
In addition, electronic health records can make it easier for doctors to follow up with patients and track continuing care, both under their supervision and that of the patient’s other doctors.
"I can quickly and easily pull up test results in the exam room to review with my patients," Sandhya Pruthi, M.D., of Mayo Clinic in Minnesota says on the Mayo Clinic website. "I also can verify when they had past exams or procedures. I can even show them results of their imaging tests on the screen."
At the very least, electronic health records can save time during a doctor’s office visit. And in case of emergency, these records can provide critical, life-saving information to emergency care providers.
People who find themselves in mass casualty situations, such as natural disasters, can benefit greatly from electronic medical records. Healthcare providers can use EHR in an emergency situation to get a more accurate picture of a patient’s medical history more quickly than with traditional means.
Catastrophic events have demonstrated that patients in these situations are often confused and frightened, making it easy to forget personal medical details. Every second counts during an emergency, so having access to a patient’s medical history, blood type and allergy information, when the patient is unable to communicate can be the difference between life and death. Also, the digital format can make quick access more scalable.
Benefits to Healthcare Providers
When a patient is under the care of multiple doctors, tracking his or her history, including allergies, blood type, current medications, past procedures and other relevant information, can be problematic when relying on paper charts. The use of electronic health records allows multiple care providers, regardless of location, to simultaneously access a patient’s record from any computer. The electronic record can provide up-to-the-minute information on the patient’s full history, including current test results and the recommendations of other physicians, allowing more efficient collaboration on multiple facets of a patient’s care.
Medical practitioners can quickly transfer patient data to other departments or providers, while also reducing errors, which yield improved results management. Both patients and employees often respond positively to these process improvements, as it can help keep a facility’s schedule on track.
Reducing medical errors is obviously of tremendous benefit to both doctor and patient. An electronic health records system of information eliminates the problem of lost and/or misplaced patient files while also naturally eliminating data errors that can occur from transcription.
According to experts, the advantages of emergency health records produce a marked increase in the health-related safety of patients.
The following are the most significant reasons why our healthcare system would benefit from the widespread transition from paper to electronic health records.
Paper records are severely limited
Much of what can be said about handwritten prescriptions can also be said about handwritten office notes. Figure 4.2 illustrates the problems with a paper record. In spite of the fact that this clinician used a template, the handwriting is illegible and the document cannot be electronically shared or stored. It is not structured data that is computable and hence shareable with other computers and systems. Other shortcomings of paper: expensive to copy, transport and store; easy to destroy; difficult to analyse and determine who has seen it; and the negative impact on the environment. Electronic patient encounters represent a quantum leap forward in legibility and the ability to rapidly retrieve information. Almost every industry is now computerised and digitised for rapid data retrieval and trend analysis. Look at the stock market or companies like Walmart or Federal Express. Why not the field of medicine?
With the relatively recent healthcare models of pay-for-performance, patient centred medical home model and accountable care organisations there are new reasons to embrace technology in order to aggregate and report results in order to receive reimbursement. It is much easier to retrieve and track patient data using an EHR and patient registries than to use labour intensive paper chart reviews. EHRs are much better organised than paper charts, allowing for faster retrieval of lab or x-ray results. It is also likely that an EHR will have an electronic problem summary list that outlines a patient’s major illnesses, surgeries, allergies and medications. How many times does a physician open a large paper chart, only to have loose lab results fall out? How many times does a physician re-order a test because the results or the chart is missing? It is important to note that paper charts are missing as much as 25% of the time, according to one study.Even if the chart is available; specifics are missing in 13.6% of patient encounters, according to another study.Table 4.1 shows the types of missing information and its frequency. According to the President’s Information Technology Advisory Committee, 20% of laboratory tests are re-ordered because previous studies are not accessible.This statistic has great patient safety, productivity and financial implications.
Need for improved efficiency and productivity
The goal is to have patient information available to anyone who needs it, when they need it and where they need it. With an EHR, lab results can be retrieved much more rapidly, thus saving time and money. It should be pointed out however, that reducing duplicated tests benefits the payers and patients and not clinicians so there is a misalignment of incentives. Moreover, an early study using computerised order entry showed that simply displaying past results reduced duplication and the cost of testing by only 13%.If lab or x-ray results are frequently missing, the implication is that they need to be repeated which adds to this country’s staggering healthcare bill. The same could be said for duplicate prescriptions. It is estimated that 31% of the United States $2.3 trillion dollar healthcare bill is for administration. EHRs are more efficient because they reduce redundant paperwork and have the capability of interfacing with a billing program that submits claims electronically. Consider what it takes to simply get the results of a lab test back to a patient using the old system. This might involve a front office clerk, a nurse and a physician. The end result is frequently placing the patient on hold or playing telephone tag. With an EHR, lab results can be forwarded via secure messaging or available for viewing via a portal. Electronic health records can help with productivity if templates are used judiciously. As noted, they allow for point and click histories and physical exams that in some cases may save time. Embedded clinical decision support is one of the newest features of a comprehensive EHR. Clinical practice guidelines, linked educational content and patient handouts can be part of the EHR. This may permit finding the answer to a medical question while the patient is still in the exam room. Several EHR companies also offer a centralised area for all physician approvals and signatures of lab work, prescriptions, etc. This should improve work flow by avoiding the need to pull multiple charts or enter multiple EHR modules. Although EHRs appear to improve overall office productivity, they commonly increase the work of clinicians, particularly with regard to data entry. We’ll discuss this further in the Loss of Productivity section.
Quality of care and patient safety
As previously suggested, an EHR should improve patient safety through many mechanisms: Improved legibility of clinical notes, Improved access anytime and anywhere, Reduced duplication, Reminders that tests or preventive services are overdue, Clinical decision support that reminds clinicians about patient allergies, correct dosage of drugs, etc., Electronic problem summary lists provide diagnoses, allergies and surgeries at a glance. In spite of the before mentioned benefits, a study by Garrido of quality process measures before and after implementation of a widespread EHR in the Kaiser Permanente system, failed to show improvement. To date there has only been one study published the authors are aware of that suggested use of an EHR decreased mortality. This particular EHR had a disease management module designed specifically for renal dialysis patients that could provide more specific medical guidelines and better data mining to potentially improve medical care. The study suggested that mortality was lower compared to a pre-implementation period and compared to a national renal dialysis registry. It is likely that healthcare is only starting to see the impact of EHRs on quality. Based on internal data Kaiser Permanente determined that the drug Vioxx had an increased risk of cardiovascular events before that information was published based on its own internal data. Similarly, within 90 minutes of learning of the withdrawal of Vioxx from the market, the Cleveland Clinic queried its EHR to see which patients were on the drug. Within seven hours they deactivated prescriptions and notified clinicians via e-mail. Quality reports are far easier to generate with an EHR compared to a paper chart that requires a chart review. Quality reports can also be generated from a data warehouse or health information organisation that receives data from an EHR and other sources. Quality reports are the backbone for healthcare reform which are discussed further in another chapter.
According to a 2006 Harris Interactive Poll for the Wall Street Journal Online, 55% of adults thought an EHR would decrease medical errors; 60% thought an EHR would reduce healthcare costs and 54% thought that the use of an EHR would influence their decision about selecting a personal physician. The Centre for Health Information Technology would argue that EHR adoption results in better customer satisfaction through fewer lost charts, faster refills and improved delivery of patient educational material. Patient portals that are part of EHRs are likely to be a source of patient satisfaction as they allow patients access to their records with multiple other functionalities such as online appointing, medication renewals, etc.
EHRs are considered by the federal government to be transformation and integral to healthcare reform. As a result, EHR reimbursement is a major focal point of the HI-TECH Act. It is the goal of the US Government to have an inter-operable electronic health record by 2014. In addition to federal government support, states and payers have initiatives to encourage EHR adoption. Many organisations state that healthcare needs to move from the cow path to the information highway. CMS is acutely aware of the potential benefits of EHRs to help coordinate and improve disease management in older patients.
The Centre for Information Technology Leadership (CITL) has suggested that ambulatory EHRs would save $44 billion yearly and eliminate more than $10 in rejected claims per patient per outpatient visit. This organisation concluded that not only would there be savings from eliminated chart rooms and record clerks; there would be a reduction in the need for transcription. There would also be fewer callbacks from pharmacists with electronic prescribing. It is likely that copying, faxing and mail expenses, chart pulls and labour costs would be reduced with EHRs, thus saving full time equivalents (FTEs). More rapid retrieval of lab and x-ray reports results in time/labour saving as does the use of templates. It appears that part of the savings is from improved coding. More efficient patient encounters mean more patients could be seen each day. Improved savings to payers from medication management is possible with reminders to use the drug of choice and generics. It should be noted that this optimistic financial projection assumed widespread EHR adoption, health information exchange, inter-operability and change in workflow. EHRs should reduce the cost of transcription if clinicians switch to speech recognition and/or template use. Because of structured documentation with templates, they may also improve the coding and billing of claims. It is not known if EHR adoption will decrease malpractice, hence saving physician and hospital costs. A 2007 Survey by the Medical Records Institute of 115 practices involving 27 specialities showed that 20% of malpractice carriers offered a discount for having an EHR in place. Of those physicians who had a malpractice case in which documentation was based on an EHR, 55% said the EHR was helpful.
The timing seems to be right for electronic records partly because the technology has evolved. The internet and World Wide Web make the application service provider (ASP) concept for an electronic health record possible. An ASP option means that the EHR software and patient data reside on a remote web server that users can access via the internet from the office, hospital or home. Computer speed, memory and bandwidth have advanced such that digital imaging is also a reality, so images can be part of an EHR system. Personal computers (PCs), laptops and tablets continue to add features and improve speed and memory while purchase costs drop. Wireless and mobile technologies permit access to the hospital information system, the electronic health record and the internet using a variety of mobile technologies. The chapter on health information exchange will point out that health information organisations can link EHRs together via a web-based exchange, in order to share information and services.
Need for integrated data
Paper health records are standalone, lacking the ability to integrate with other paper forms or information. The ability to integrate health records with a variety of other services and information and to share the information is critical to the future of healthcare reform. Digital, unlike paper-based healthcare information can be integrated with multiple internal and external applications:
EHR is a transformation tool
It is widely agreed that US Healthcare needs reform in multiple areas. To modernise its infrastructure healthcare would need to have widespread adoption of EHRs. Large organisations such as the Veterans Health Administration and Kaiser Permanente use robust EHRs (VistA and Epic) that generate enough data to change the practice of medicine. In 2009 Kaiser Permanente reported two studies, one pertaining to the management of bone disease (osteoporosis) and the other chronic kidney disease. They were able to show that with their EHR they could focus on patients at risk and use all of the tools available to improve disease management and population health.In another study reported in 2009 Kaiser-Permanente reported that electronic visits that are part of the electronic health record system were likely responsible for a 26.2% decrease in office visits over a four year period. They posited that this was good news for a system that aligns incentives with quality, regardless whether the visit was virtual or face-to-face. Other fee-for-service organisations might find this alarming if office visits decreased and e-visits were not reimbursed. Kaiser also touts a total joint registry of over 100,000 patients with data generated from its universal EHR. As a result of their comprehensive EHR (KP Health-Connect) and visionary leadership they have seen improvement in standardisation of care, care coordination and population health. They also have been able to experience advanced EHR data analytics with their Virtual Data Warehouse, use of artificial intelligence and use of computerised simulation models (Archimedes). In addition they have begun the process of collecting genomic information for future linking to their electronic records.
Communication gaps and data-sharing challenges are pervasive in healthcare, persisting between different providers, hospitals and payers, and even various departments within a health system. While technology promises a future of connected networks and free-flowing information, the challenge remains bridging the gap between data silos to improve patient care.
Connecting the plethora of data sources relevant to patient outcomes and care management is overwhelmingly cumbersome. The burdensome task of integrating all of these data sources distracts organizations from their core competency, effectively acting as a blockade to healthcare innovation. Clinical health records, including both primary care and hospital visits; payment information and history; patient-generated health data; pharmacy and prescription information; patient and family-health history; genomics; clinical-trial data; and so on – all of this information needs to be easily accessible digitally for providers as well as patients to realize the full potential and promise of interoperability.
Traditional EHR companies such as Cerner, Meditech, and Inter-systems are building patient-management tools that will help coordinate a patient's care beyond the four walls of any one health system. Healthcare technology leaders, like the aforementioned, are taking steps to capture patient-generated health data from outside of the clinical setting and bring it back into the patient's clinical story.
A common misconception is that EHRs are the lone solution to interoperability. EHRs were not designed as open systems that can easily pull in information from outside the clinical setting or connect data across multiple providers. Rather, these tools were created to coordinate patient care within a hospital, replacing paper records and filing cabinets. EHR vendors are unfairly blamed for the fact that healthcare is not more interoperable. Like any technology company, they build what their customers want to buy. EHRs are a part of the overall solution to interoperability; really, all healthcare technology is only part of the means to which we will achieve interoperability. Changes to physician workflow and new models of care – working in parallel with technology such as EHRs, patient portals and care management tools – are necessary for interoperability to be fully achieved.
We need buy-in from physicians and administrators to build care programs utilizing this technology. Too often, care teams are spending their time calling other providers about patient information, faxing paper records and trying to coordinate care efforts across a disjointed and disconnected system. This is a drain on resources that could be better spent with patients on site or remotely monitoring patients with chronic conditions. We need a network connecting this data to create more effective workflows, care coordination, and prevention-based models of care.
Whatever you choose to call it (interoperability, data liquidity or care coordination), we need data to flow easily throughout the healthcare ecosystem to improve the lives of patients. Expecting EHR vendors to solve this challenge alone will further delay an already long-overdue solution. We need all stakeholders – patients, physicians, technology companies, providers and payers to challenge existing conventions in order to make interoperability a reality.
It is tempting to believe that your hospital is now paperless once you’ve implemented an electronic medical record (EMR) system or completed an EHR conversion. While EHRs are the biggest step toward going paperless, most organizations still manage volumes of paper which prevents the establishment of a truly integrated care team – one in which all information is available to all providers in near real time. Organizations that are not completely paperless cannot meet HIMSS Stage 7: a full digital environment where all clinical documents are available electronically within 24 hours of creation or receipt. Documents such as outside records, telemetry strips, ancillary results, signed consents, and “shadow charts” that are part of a patient’s overall record often remain on paper, and leave healthcare organizations with paper to manage and a disjointed care environment. The good news is that going paperless can be achieved in a variety of patient care settings and with minimal disruption.
Eventually it will be possible for patients, healthcare staff and clinicians to enter all data into a patient’s EHR and little or no paper will be required. Until then, improved workflows and exciting new technology can support going virtually paperless. Interested? Then keep in mind a few facts, and don’t let them go as you consider implementing at your facility:
1. With the right technology, scanning can take LESS time than filing to a paper chart
2. Scanning is a form of clinical documentation, it is NOT an “administrative task”
Paperless Is Possible
At Freed Associates, we’ve worked with several healthcare organizations, both large (400 beds) and small (30 beds), to implement a decentralized Point of Service (POS) scanning model to create paperless systems that are improving quality of care, safety and performance. This POS model required the real time scanning of thousands of pages in clinical and registration settings. It eliminated virtually all paper, and expedited the creation of a single and complete EHR. Physicians and care providers no longer have to wonder where documents are or when they will be viewable in the chart.